Provider Demographics
NPI:1700997194
Name:MANGUIAT-LANG, KIMBERLEE MAY
Entity Type:Individual
Prefix:
First Name:KIMBERLEE
Middle Name:MAY
Last Name:MANGUIAT-LANG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLEE
Other - Middle Name:MAY
Other - Last Name:MANGUIAT-LANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:420 POLIFKA DR BLDG 1042
Mailing Address - Street 2:
Mailing Address - City:SHAW AFB
Mailing Address - State:SC
Mailing Address - Zip Code:29152-5100
Mailing Address - Country:US
Mailing Address - Phone:803-895-1216
Mailing Address - Fax:
Practice Address - Street 1:420 POLIFKA DR BLDG 1042
Practice Address - Street 2:
Practice Address - City:SHAW AFB
Practice Address - State:SC
Practice Address - Zip Code:29152-5100
Practice Address - Country:US
Practice Address - Phone:803-895-1216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4052133N00000X
813967133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist